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Publications and Forms

Employer's Affidavit for Religious Exception (WC-138-5)

The affidavit to be completed by an employer when requesting for an employee to be exempt from workers' compensation due to religious reasons.

Escrow Agreement (WC-82E)

An Escrow Agreement; one of three options available to meet the self-insurance security requirement.

Group Insurance Checklist (WC-239)

The checklist of required items and information that must accompany the Application for Self-Insurance Trust (WC-81A).

Guaranty to Satisfy Compensation Claims Under Workers’ Compensation Law of Missouri (WC-82A)

A guaranty of a third party to satisfy an individually self-insured employer’s workers’ compensation obligations under Missouri law.

Information for Appeals Tribunal Hearings (MODES-INF-166)

Information for Appeals Tribunal hearings, including what they are, instructions, and other important facts to know.

Joint Motion for Change of Venue (WC-281)

This form allows attorneys that are parties to a case to jointly submit a motion for change of venue.  All parties must agree to the change of venue. 

Payroll Records Required By Law (MODES-31)

A poster containing information about payroll records to be displayed in workplace.

Physicians Report on Eye Injuries (WC-241)

A form to be completed by physician examining a workers compensation eye injury.

Quarterly Wage Report Continuation Sheet (MODES-10B)

The Division uses the Quarterly Wage Report Continuation Sheet to allow reporting of additional employees when there are more employees than will fit on the Quarterly Contribution and Wage Report (MODES-4). This form MODES-10B should be attached to the MODES-4.